Overview of HIV/AIDS in Ethiopia Unit 1 HIV Care and ART: A Course for Healthcare Providers Unit 1 should take approximately 1 hour 45 minutes to implement. Step 1: Opening Addresses by Coordinating Sponsors of Training (Slide 1) – 15 minutes Step 2: Introduction to HIV Care and ART Training Workshop Overview of Unit 1 Learning Objectives (Slide 2-3) – 5 minutes Step 3: Global and National Summary of HIV/AIDS Epidemic (Slides 4 – 35) – 60 minutes Step 4: Policy of ARV Supply and Use in Ethiopia (Slides 36 – 45) – 20 minutes Step 5: Key Points (Slides 46 – 47) – 5 minutes

Learning Objectives Describe the national HIV/AIDS epidemiological profile Describe the Ethiopian national AIDS strategies, guideline for implementation of ART, and roadmap to accelerate care and treatment for PLWHA List the major achievements, challenges and opportunities during the implementation of the ART program in Ethiopia Step 2: Introduction to HIV Care and ART Training Workshop Overview of Unit 1 Learning Objectives (Slide 2-3) – 5 minutes Explain that this session provides an opportunity to discuss the broader picture of HIV/AIDS in Ethiopia, including national policies and guidelines. Some of the information may be a review, while some may be new. This information will be key to the ongoing discussion of structural challenges and implementation strategies. Discussion of clinical and technical information begins in the next unit. Review the unit aim and objectives. The aim of this unit is to review the status of HIV/AIDS in Ethiopia and national policy responses to antiretroviral therapy (ART). The unit discusses the global HIV/AIDS epidemic, HIV prevalence rates and trends in Ethiopia, and government responses to HIV. Ask if participants have any questions before continuing.

Learning Objectives (2) Explain the Ethiopian National Policy on ARV drugs, supply and use Convey the current status of the ART program in Ethiopia List prevention strategies to reduce the spread of HIV infection in the country

Global and Ethiopian Summary of HIV/AIDS Epidemic Step 3: Global and National Summary of HIV/AIDS Epidemic (Slides 4 – 35) – 60 minutes

Global Summary of the AIDS Epidemic, December 2005 PLWHA 40.3 million (36.7 – 45.3) Adults 38.0 Million (34.5-42.6) Women 17.5 Million (16.2-19.3) Children <15 yrs 2.3 Million (2.1-2.8) New infections 4.9 million (4.3–6.6) Adults 4.2 Million (3.6-5.8) Children <15 yrs 700,000 (630,000 – 820,000) AIDS Deaths 3.1 million (2.8 – 3.6) Adults 2.6 Million (2.3 – 2.9 million) Children <15 yrs (570,000-670,000) Source: WHO/UNAIDS AIDS Epidemic Update, December 2005.

Global Picture of HIV/AIDS Source: UNAIDS. 2006 Report on the global AIDS epidemic. May 2006. Available at http://www.unaids.org/en/HIV_data/Epidemiology/epi_slides.asp Source: UNAIDS, 2006

Est. Number Newly Infected With HIV During 2005: 4.9 Million Western Europe 21,000 Eastern Europe & Central Asia 210,000 North America 44,000 East Asia & Pacific 290,000 North Africa & Middle East 92,000 South & South-East Asia 890,000 Caribbean 53,000 Sub-Saharan Africa 3.1 million Latin America 240,000 Australia & New Zealand 5,000 This slide shows the global distribution of new HIV infections. Source: UNAIDS/WHO

Est. Adult and Child Deaths From HIV/AIDS During 2005: 3.1 Million Western Europe 65,000 Eastern Europe & Central Asia 60,000 North America 16,000 North Africa & Middle East 28,000 East Asia & Pacific 51,000 Caribbean 36,000 South & South-East Asia 490,000 Sub-Saharan Africa 2.3 million Australia & New Zealand 700 Latin America 95,000 Source: UNAIDS/WHO

More than three quarters of all young people living with HIV are women (WHO Regional Office for Africa, 2003; Reproductive Health Research Unit and Medical Research Council, 2004). Source: UNAIDS/WHO 2004

Ethiopian Prevalence National prevalence for 2003 ......... 4.4% Women….5.0% Men….3.8% Urban prevalence in 2003...................12.6% Urban prevalence in 2005...................12.5% Rural prevalence in 2003 .................. .2.6% Rural prevalence in 2005................... .3.0% Addis Ababa prevalence in 2003 ........14.6% Addis Ababa prevalence in 2005 ........14.5% Source: Overview of HIV care in Ethiopia, HAPCO/MOH, March 2006

HIV/AIDS Indicators in Ethiopia (2005) Number of PLWHA 1.7 million Estimated AIDS cases 143,129 PLWHA requiring ARVs 286,258 Annual AIDS deaths 134,124 Adults and Children on ART 20,477 Source: Overview of HIV care in Ethiopia, HAPCO/MOH, March 2006

HIV/AIDS Indicators in Ethiopia (2005) (2) AIDS orphans 678,936 Total orphans 4,801,219 Children living with HIV/AIDS 111,903 New HIV infections………39,886 New AIDS cases…………29,359 Annual AIDS deaths in children 28,693 Children newly needing ART 58,718 Children on ART 654 Source: Overview of HIV care in Ethiopia, HAPCO/MOH, March 2006

Age & Sex Distribution of Reported AIDS Cases (1986 - June 2003, Ethiopia) Source: AIDS in Ethiopia, 5th ed., MOH, July, 2004

Pregnant Women Testing HIV Positive: Urban, 2001 Source: Aids in Ethiopia, 4th ed., MOH, October 2002

Pregnant Women Testing HIV Positive: Rural, 2001 Source: Aids in Ethiopia, 4th ed., MOH, October 2002

HIV Prevalence Among Pregnant Women by Age, Urban 2001 Source: Aids in Ethiopia, 4th ed., MOH, October 2002

Impact on Rural Households Loss of income (50% or more) Loss of labor Loss of skilled manpower and knowledge Loss of land Loss of remittances Reduction in savings and investment Expenses for treatment, funeral, teskar Need to sell livestock to meet expenses

Impact on Industry Loss of workers Expenses for recruiting and training replacements Reduced productivity in cases of skilled workers or managers Lost work days due to sickness and funeral leave Increased health care costs 50% illness due to AIDS Loss of skilled professionals

HIV/AIDS Treatment in Ethiopia Step 4: HIV/AIDS Treatment in Ethiopia (Slides 19-35) - Time

Historical Overview of HIV/AIDS in Ethiopia 1984: The first evidence of HIV infection in Ethiopia 1986: The first two AIDS cases reported to the Ministry of Health 1989: HIV/AIDS surveillance started March, 2005: Free ART program started Currently, approximately: 129 surveillance sites 73 ART sites 658 VCT sites Source: HAPCO

VCT Site Distribution by Region, 2005 Source: Overview of HIV care in Ethiopia, HAPCO/MOH, March 2006

ART Site Distribution by Region Total =73 Source: Overview of HIV care in Ethiopia, HAPCO/MOH, March 2006

Regional Distribution of ART

PMTCT Site Distribution, by Region Total site = 129 Source: Overview of HIV care in Ethiopia, HAPCO/MOH, March 2006

National Response HIV/AIDS Policy formulated by MOH and adopted by the Council of Ministers in 1998 Enabled HIV/AIDS prevention and control Supplemented existing health, women’s, and education and training policy Called for a multisectoral response Guaranteed rights of PLWHA ARV Drugs Supply & Use Policy formulated July 2002

National Response (2) HIV/AIDS Prevention & Control Office (HAPCO) established June 2002 Restructured from NACS (April 2000) Sits under Prime Minister’s Office Established at all levels of government Runs the daily activities of NAC Resource mobilization Advocacy Coordination of the sectoral responses

National Response (3) HIV/AIDS Strategic plan for five years 2004 - 2008 Social mobilization & community involvement Community ownership Scaled up ART program AIDS fund was initiated Free ART program was scaled up

HIV/AIDS Intervention Strategies Prevention Social mobilization IEC/BCC HIV counseling and testing Voluntary (VCT) Provider initiated (PIHCT) STI prevention and control Condom promotion Infection prevention Prevention of mother to child transmission (PMTCT) Post exposure prophylaxis

HIV/AIDS Intervention Strategies (2) Care and Treatment Palliative care Community home based care Opportunistic infection treatment Tuberculosis treatment Treatment of AIDS patients Support for Orphans and vulnerable children (OVC) People living with HIV/AIDS (PLWHA)

Major Achievements National HIV/AIDS Policy National AIDS Council Secretariat Five editions of “AIDS in Ethiopia” National ARV Policy (revised and published in January 2005) Roadmap to accelerate access to HIV/AIDS care and treatment M&E framework

Major Achievements (2) Five-year strategic plan revised & updated Used as main input for the National Strategic Framework adopted by NAC Contains strategic outline of interventions at federal and regional levels Key guidelines developed: HIV Surveillance Guideline HIV Surveillance Training Manual Voluntary Counseling & Testing Guideline

Major Achievements (3) Key guidelines (continued): AIDS Case Management Guideline STI Management Guideline Home-Based Care Guideline Private HIV Labs Licensing Guideline PMTCT Guideline Home Care Training Manual Counseling Training Manual ARV Guideline Universal Precautions & Post Exposure Prophylaxis

Major Achievements (4) 658 VCT sites established 129 sentinel surveillance sites established MOH has been the primary advocate for a multi-sectoral response to HIV/AIDS: Formulated and disseminated HIV/AIDS and ARV Drugs Supply & Use Policies Acts as a catalyst for several multi-sectoral HIV/AIDS committees that pre-dated the NAC

Major Achievements (5) Integrating HIV/AIDS into health programs: Reproductive health Mother and child health Hospital hygiene Health education Integrated disease surveillance TB/HIV Initiative

Limitations Synchronizing pharmacy & patients reports Absence of laboratory reports Inadequate Pre and ART registers Employing ART coordinators and Data managers Sending reports to RHBs and MOH AIDS patients on waiting lists

Policy of ARV Supply and Use in Ethiopia Step 4: Policy of ARV Supply and Use in Ethiopia (Slides 36 – 45) – 20 minutes

Introduction Care and support of PLWHA plays an important role in preventing the spread of HIV/AIDS ART is an important component of care for PLWHA ARVs also have an important place in PMTCT and PEP ARVs have enormous benefits, but affordability, toxicity, adherence and resistance are challenging

National ARV Policy Policy approved in July 2002 Objectives of the policy: Reduce MTCT Prolong and improve the quality of lives of PLWHA Reduce accidental HIV infection within health institutions

General Policy Determines type of ARVs that will be used in health care services The Government of Ethiopia: Coordinates & facilitates the supply of ARVs Builds capacity for making available safe, effective and quality antiretroviral drugs, and for ensuring proper use of these drugs Ensures sustainable supply of ARVs by encouraging involvement of all stakeholders

General Policy (2) The Government of Ethiopia (cont): Nurtures international partnerships to strengthen sustainable supply and use of ARVs Encourages research on modern and traditional HIV/AIDS treatment Establishes strong systems to monitor ARV supply and use

General Strategies Selection of ARVs Determine the type of ARVs to be used in Ethiopia Incorporate selected ARVs into the national drug list Permit the import of ARVs that are not included in the national drug list

General Strategies (2) Supply of ARVs ARVs for ART: Exempted from taxation Supplied at reduced prices through government negotiation with manufacturers, importers and distributors Purchased by a system of bulk and generic substitution Local production of ARVs encouraged Benefaction of ARVs facilitated by the Ethiopian Government Ethiopian Government supplies ARVs for PMTCT Supply of ARVs: Encourage the establishment of international drug initiatives Create an enabling environment for drug research Encourage the private sector to produce generic drugs locally Encourage all stakeholders to supply drugs to the community

General Strategies (3) Drug Use Prepare and implement standardized prescription paper Prepare and implement national guidelines for safe and effective use of ARVs Sustainable public education on ARV drugs  ARVs Prescribe in authorized health institutions by trained physicians using the national treatment guideline Dispense in authorized retail outlets by trained pharmacists or pharmacy personnel Establish a system of ensuring patient adherence

General Strategies (4) Research and Development Government of Ethiopia encourages research on modern and traditional HIV/AIDS treatment Government of Ethiopia shall make efforts to strengthen the capacity of research institutions Rights and benefits of citizens that enroll in research studies shall be respected National and international ethical norms and values in human experimentations shall be observed

Scaling up ART Uptake Need capacity development to: Initiate treatment Help patients adhere to their treatment regimens Monitor the efficacy and toxicity of the regimens Diagnose treatment failure Monitor overall resistance in society ART program must be implemented at Health Center level Nursing initiative to prescribe ARVs is being piloted

Key Points AIDS is a global, regional, and national crisis The national HIV seroprevalence rate in Ethiopia is 4.7% Urban rate is 12.5% Rate in Addis Ababa is 14.5% Approximately 20,500 people in Ethiopia are currently receiving ART Step 5: Key Points (Slides 46 – 47) – 5 minutes Summarize the presentation, review the Key Points presented in this unit and answer final questions.

Key Points (2) ARV guidelines have been written, policies have been adopted, and training is being conducted in Ethiopia ARVs have enormous benefits and challenges. The challenges include: Developing capacity to initiate treatment Supporting adherence Monitoring efficacy and toxicity Diagnosing treatment failure Monitoring resistance